Researchers show how brain connections, or synapses, are lost early in Alzheimer's disease and demonstrate that the process starts -- and could potentially be halted -- before telltale plaques accumulate in the brain. Their work, published by Science, suggests new therapeutic targets to preserve cognitive function early in Alzheimer's disease.

The researchers show in multiple mouse models of Alzheimer's that mechanisms similar to those used to "prune" excess synapses in the healthy developing brain are wrongly activated later in life. By blocking these mechanisms, they were able to reduce synapse loss in the mice.

Currently, there are five FDA-approved drugs for Alzheimer's, but these only boost cognition temporarily and do not address the root causes of cognitive impairment in Alzheimer's. Many newer drugs in the pipeline seek to eliminate amyloid plaque deposits or reduce inflammation in the brain, but the new research from Boston Children's suggests that Alzheimer's could be targeted much earlier, before these pathologic changes occur.

In the Alzheimer's mouse models, the team showed that synapse loss requires the activation of a protein called C1q, which "tags" synapses for elimination. Immune cells in the brain called microglia then "eat" the synapses -- similar to what occurs during normal brain development. In the mice, C1q became more abundant around vulnerable synapses before amyloid plaque deposits could be observed.

When researchers blocked C1q, a downstream protein called C3, or the C3 receptor on microglia, synapse loss did not occur. The beta-amyloid protein, C1q and microglia work together to cause synapse loss in the early stages of Alzheimer's. The oligomeric form of beta-amyloid (multiple units of beta-amyloid strung together) is already known to be toxic to synapses even before it forms plaque deposits, but the study showed that C1q is necessary for this effect. The converse was also true: microglia engulfed synapses only when oligomeric beta-amyloid was present.

"Microglia and complement are already known to be involved in Alzheimer's disease, but they have been largely regarded as a secondary event related to plaque-related neuroinflammation, a prominent feature in progressed stages of Alzheimer's," notes Science paper's first author. "Our study challenges this view and provides evidence that complement and microglia are involved much earlier in the disease process, when synapses are already vulnerable, and could potentially be targeted to preserve synaptic health."

A human form of the antibody Stevens and Hong used to block C1q, known as ANX-005, is in early therapeutic development with Annexon Biosciences (San Francisco) and is being advanced into the clinic. The researchers believe it has potential to be used someday to protect against synapse loss in a variety of neurodegenerative diseases.